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Home My WebLink About1549 MAIN ST./RTE 6A(W.BARN.) - Health 1549 Main Street/Rte 6A (W.Barn) W. Barnstable P A = 197 007 No. 'T Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippfication for Misposal bpstem Construction permit Application for a Permit to Construct( ) Repair pg ade r ) Abandon( ) El Complete System ndividual Components Location Address or Lot No. ffll.• Owner's Name,Address,and Tel.No.9 t Assessor's M`ap/Parcel 0 u c �t eN �.0 a In ��(j1 Installer:p Name,Address, iyl TeI.� .. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of l3epairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental de and not to place the sy e in operation until a Certificate of Compliance has been issued by thi oard o alth. Sign Date Application Approved by Date �- Application Disapproved by Date for the following reasons Permit No. '' Date Issued -------- - --- --------- -- ------- - N Fee - THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS is osaYi*pstern 0onstrurtion Permit Application for a Permit to Construct( ) Repair(3�_u de O Abandon( ) ❑Complete System ❑,i'Individual Components Location Address or Lot No. �� V t .�¢- Owner's Name,Address,and Tel.No. Assessor'srMap/Parc C! 0-7 Installer's Name,Address, d Tel.NA,,.1 � Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms i�J �J"F Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures . Design Flow(min.required) gpd Design flow provided /!�1 /� gpd Plan Date Number of sheets Revision Date Title �t Size of Septic Tank Type of S.A.S. Description of Soil Nature of epairs or Alterations(Answer when applicable) >�lA � Dk t� r, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Qode and not to place the sy!tem in operation until a Certificate of Compliance has been issued by tgnhi's Boa dr of.Health. Date �Si ed Application Approved by Date Application Disapproved by Date t for the following reasons ' Permit No. ., ^�+-* '� Date Issued Gr� 1 ` ' rt } THE COMMONWEALTH OF MASSACHUSETTS J ® BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that �the On-site SewageDisposal system Constructed gepaired(li) Upgraded( ) Abandoned( by at raj �VI / ;Cs�/t, has been constructed in accordance r r with the provisions of Title 5 and#e for Disposal System Construction Permit No:"�y= t dated fd}/t Installer < Designer #bedrooms '0 1 ft Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system w lMnc)t(i/An as designed.. r Date f � 1 Inspector�_ r.r( '�./ - --------------- - --f�- ---- -- - -------------------------- - ---- - - - -•---------•--- --------- -- -=--- ----_ Now Fee T THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Mis osai 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(v) Upgrade( ) Abandon( ) System located at ,S (�{ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must,be aim leted within three years of the date of this4permit. Date /4! Approved yam•., _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M y< 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every west Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is west Barnstable Ma 02668 6/11/2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with'a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ I❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owners Name information is required for every West Barnstable Ma 02668 6/11/2016 � page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d private well 9 ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 311 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2x1000 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): One leach pit was video inspected from the d-box and was found to have 1' standing water with no signs of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every west Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - tD�'t tuw � �p Fa W'eaT L�irstpbw PI p t t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I _ SEWAGE INSPECTIONS LOC6 , n (A DATE V'LLAGEOzzi /3a,znztag.Qc /'7n�h. 6/12/03 INS i;. ASSESSOR'S MAP & LOT 797- 07 ECTOR o.ae h P. t7aeomge2 a2. SEPTIC TANK CAPACITY 7000 a�Ponz f /3ox LEACIIVC FACILITY: (typ�)Z_L/�_�OUO' NO. OFBEDROOMS p (size)3, 000 ya2.Qon3 BUILDER OR OWNER - hn /2�clza2cl�on � OWNER MAILING ADDRESS o h n �. /� _cha2daon } 70 R_jnygoP.t Road K zn ylzam, Naa13. 0204 3 I 1 / S i �= • TOWN OF BARNSTABLE LOC,X iiON Al-42 kJe_— 1� SEWAGE 173 VILLAGE I.,', �3g�n C j�6 j� ASSESSOR'S MAP & LOT 66 INSTALLER'S NAME & PHONE ..,PTIC TANK CAPACITY F -EACHING FACILITY:(type) ��'?" (size) c NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: ,/6 73 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No • 6 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove Owner Owner's Name information is required for every West Barnstable Ma 02668 6/11/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 1549 Rt 6A West Barnstable is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts /97L ' b Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1549 Route 6A Property Address Robert Raylove W Owner Owner's Name f.► information is Qy required for every West Barnstable Ma 02668 6/11/2016 page. Citylrown State Zip Code Date of Inspection �.. N Fr Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms (I on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection �y Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/11/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 4ow VS ENVIROTECH LABORATORIES,INC. MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Un1112 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name Raylove,Robert Location 1549 Main Street Address 1549 Maim St W Barnstable,Ma W Barnstable,MA 02668 Sample Date 06/13/16 Collected By Enviro Sample Time 14:35 Sample Type Drinking Water Date Received w13i16 Lab Order Number DW-161758 Well Specs - t s._ Analysis Requested Units Recommended Vinlis AnalysisResnIll Method lftleAnalyzedl Analyzed Dy Total Coliform CPU/100mL 0 0 SM9222B 6/13/2016 RS _....._..._._.. ..._.._...._.. ...-- -- ................ .................. . . PH pH units 6.5-8.5 9.22 SM 4500-H-B 6/13/2016 LL Specific Conductancen umhos/cm 600 143 EPA 120.1 6/13/2016 LL . . ........................................... . .. .. ...-- --.......-......_........ _.._. Nitrite-N mg/L 1.00 <0.006 EPA 300.0 6/13/2016 LL Nitrate-N mg/L 10.0 <0.01 EPA 300.0 6/13/2016 LL .......... - -..-._.__........__...._ .... - ------------ - _...._ Sodium mg/L 20.0 8.2 EPA 200.7 6/14/2016 MC ............... --------. ... . .. .. ......... - - --------- -..._......._...... . .. . Total Ironn mg/L 0.3 0.02 EPA 200.7 6/14/2016 MC Manganeser, mg/L -0.05 0.013 EPA 200.7 6/14/2016 MC - ' Volatile Organic Compounds ug/L See comment. None Detected EPA 524.2 6/15/2016Irk RS w pH is above recommended liMUM uld be adjusted. " Water meets standards s able for drinking for parameters tested. Date 6/16/2016 onald .S ri Labor o Director BRL=Below Reportable Limits "See Attached Page 1 of 1 cCertification is not available for this analyte for non potable water samples.. L` G) 00l �- � Fee ---- BOARD OF HEALTH TOWN OF BARNSTABLE Zippticationfor; eYY Cootruct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (�an individual Well at: -. �'ti___ _--- — --— - -�-= ��-- -- Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address Type of Building Dwelling Other - Type of Building-=--_—_--._-____ No. of Type of Well ---- Purpose of Well--- �� .---l�,c�f --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection egulation - The undersigned further agrees not to place the well in operation untilCrtfcat . f Compliance His been issued by the Board of Health. Signed ------ -- - f- 4LZ - date Application Approved By ___--------- `' r 2? (Z__ date Application Disapproved for the foll mg reasons: date Permit No: f — t KJ -- Issued--_ b-— --- �— ----------------- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate Of (Compliance THIS IS TO CERTI�Y, tat the Irjdividual Well Constructed ( ), Altered ( ), or Repaired by------ _---�1--_------------- —__. - -----------------------------------------__—_---- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. j�a01 -d 6-Dated --a�- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE —'r!-'Z Inspector-------- ----- -------- G� 2� ► � �bl L( 5 No.-------- ---- Fee-------------------- BOARD OF HEALTH TOWN OF BARNSTABLE 2pplication for Veil �tCon5truttio' Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel °e wner Address --- s1---------- i Installer — Driller Address Type of Building Dwelling Other - Type of Building-=—--__--__— No, of Persons--- -.-- . e1p Type of Well— V ---__—_ Capacity---------------_--__---___—_—_ Purpose of Well-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificati bf Compliance has been issued by the Board of Health. Signed ----------- - 25"4 Z' - / date Application Approved By. —______ _�Z--__ date _— Application Disapproved for the foll ng reasons: date Permit No. ^ Issued—_—�- ! -/ ----_—_ date BOARD OF HEALTH TOWN OF BARNSTABLE uC ertif irate Of Compliance i I THIS IS TO CERTI ,,,;F�►at the I dividual Well Constructed ( ), Altered ( ), or Repaired �Q by------ _— .t—�--- ---- — -----—___—__ __ -- -- --- --- _Installer Kr_ at-_ ► _ --- —------------------------- -- ---- --- - ,has been installed in accordance with the provisions of the Town-of Barnstable Board of;Health Private Well Protection i Regulation as described in the application for Well Construction Permit No. Waai� ---------_--Dated--------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - - Inspector--------------------_------------�---- BOARD OF HEALTH TOWN OF BARNSTABLE ]Veil Con5truct ion Permit No. dc Fee f Permission is hereby granted to Construct ( ), Alter ( ), or Repair K) an Individual Well at: 151-M ' No. Street as shown on the application for a Well Construction Permit � No. Dated_:- - - ----------------------------------- DATE -'�`" Board of Health i i z OE aiiiys a80 CERTIFICATE OF ANALYSIS Page: 1 , Barnstable County Health Laboratory Repo Pre ared For: Report Dated: 9/18/2003 D --t Order N mbRECF3 322539 Robert Raylove 1750 Main Street SEp 2 6 2003 West Barnstable, MA 02668 TOWN 0+ EP. Laboratory ID#: 0322539-01 Description: Water-Drinking Water Sample#: 22539 Sampline Location: 1549 Main Street W Barnstable VIA Collected 8/27/2003 Collected by: R Raylove 197-007 Received 8/27/2003 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 12.2 mg/L, 10 EPA 300.0 8/28/2003 LAB: Metals Copper 0.2 mg/L 1.3 SM 3111E 9/10/2003 Iron 0.3 mg/L 0.3 SM 3111 B 9/10/2003 Sodium 250 mg/L 20 SM 3111E 4/10/2003 LAB: Microbiology Total Coliform Absent P/A Absent 307 8/27/2003 LAB:Physical Chemistry Conductance 1225 umohs/cm EPA 120.1 8/27/2003 pH 5.8 pH-units EPA 150.1 8/27/2003 Note: Nitrate water sample level exceeds the recommended maximum contamination level for drinking water.Sodium level very high.Client may wish to speak with physician. r Approved By: Director) C� Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r =' Page: 1 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory ,g�ss�cttust;. Report Prepared For: Report Dated: 10/15/2003 Order Number: G0323013 Robert Raylove 1750 Main Street West Barnstable, MA 02668 Laboratory ID#: 0323013-01 Description: Water-Drinking Water Sample#: 23013 Sampline Location: 1549 Main Street, West Barnstable Collected 9/30/2003 Collected by: R.Raylove Received 9/30/2003 Test Parameters ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 8.3 mg/L 10 EPA 300.0 10/2/2003 LAB: Metals Sodium 178 mg/L 20 SM 3111E 10/9/2003 Note: Sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upward trends. Sodium level higher than average.Those on low sodium diet may wish to-consult physician. Approved By: b Director) �d S103 Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 SEWAGE INSPECTIONS LC,'A'I N! 1549 Rouie 64 DATE 6112103 VELLAGEYezt L3a2n�ta��e, (7a��. ASSESSOR'S MAP & LOT �97-UU7 -INSJ,�FCTOR jo.6elzh P. Macom&e2 aa. SEPTIC TANK CAPACITY 1000 aai eonh f Box LEACHING FACILITY: (type)?-LP-1000',6 (size)3, 000 gaiion.6 NO. OF BEDROOMS 2 BT.MDEROR OWNER,F.�C�s�� D aohn Richalzdzon OWNER MAILING ADDRESS` •;ohn E. Richa zd.6on 90 Ringgoi.t Road 11,ngham, Ma.6.6. 02043 _ j 154R IZcrai-e (,v tisk �tj�rv.s�a�ol-c �� : / .elf r r• OAT E : 6/12/03 PROPERTY ADORESS:1549 Roate 6A .s.t Baan.etag.Pe .s�s. lJe , Ma 02668 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: ED]EPT. 1 . 1- 1000 gaiion ze/2t.ic .tank. ". 1-Dizta.i&at.ion Sox. 3. 2- 1000 ga2.2on /2aecazt ieach.ing pitz. Based on my inspection, I certify the following conditions: F BARNSTABLE t. 7hiz .iz a t.it.ie �iye Ze/2t.ic bybt�m. (78 Code) 5. The ze/2t.ic zyztem .iz .in /2ao/1ea woak.ing oadea at the /14ezent time. 5. Both o� the .2each.ing /2.itz aae /aaezent ey day. SIGNATUR Name : - J-.- P . -Macomber-Jr . - -- ------- ------- Company :j4ageh per_ M��gntt 8_ Son, Inc . address __�Qx ............ Celtisz �ciLL�,_Ja .._Q2632-0066 Pnone : __508- 775_ 3338 -------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY :P.OBox P. MACOMBER & SON, INC. anks-Cesspools-Leachf lelds Pumped & Installed Town Sewer Connections 66 Centerville. MA 02632.0066 775.3338 775.6412 S -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1549 /2o ut e 6 A G/P iY /3a ?n.siaF—Pv, NriA.5. Owner's Name: E.s,.-ale 0. John /2.ichazd.6on Owner's Address: 1(1 /?i n giO n-Pf /?n n rL Date of Inspection: 617210 Name of Inspector: (please print) Joseph P. Macomge2 ait. Company Name:1. P. Nacom9ea 9 Son Inc. Mailing AddressQo x 66 CP-n1jP1?n.%_.P.PD, tlri iA. 02632 Telephone Number: 5 Q R_7 7 5_ 3 3 3 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: -,/—i/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1549 Rout e 6A I eet Ba/cneta e ae.6. Owner: Eztate 0 o n / zc a2 .60n Date of Inspection: 6112103 Inspection S : Cbeck A,B,C,D or E/ L� WAYS complete all of Section D >> System Passes: t /) I have not found any information which indicates that any of the failure.cnt�e)''a described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not'evaluated are,indicuitet relow. / . . / �I 11 Comments: _7hp .septic .6uetem .ins _,in /2/zo/2e/t wozk.ing oade/t a.t Ahe nn0Aen7 Limp, B. System Conditionally Passes: 40 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. ,,06 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is strucrurally' unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A.*metal sepric tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 15 4 9 R o u.t e 6 R e.6 a zn.6 a e, a s.a. Owner: &3 al-e o n / .cc a2 .6on Date of Inspection: 6112103 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: 40 Cesspool or privy is within 50 feet of a surface water Z Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: /VU The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. k6 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 4,ZQ The system has a septic tank and SAS and the SAS is less than 1 Kfeet�50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: A Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:1 549 Route 64 6)e.61 4aan6.ta9 e,dazz, Owner: z i 04 _�ohn RinhrindA n Date of Inspection: 6/1?/0 3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 7Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in 1he distribution bo above outlet invert due to an overloaded or clogged SAS or —/ cesspool _ d Liquid depth ineesspvel•is less than 6"below invert or available volume is less than h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number /of times pumped Q. _ AL y portion of the SAS,cesspool or privy is below high groundwater elevation. �y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ V y portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ he system is within 400 feet of a surface drinking water supply !/the system is within 200 feet of a tributary to a surface drinking water supply v _ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:1 5 4 9 Route 6A Oezt Ba/Ln-6ta e, ( azz. Owner:Eztate Uie John Richaadzon Date of Inspection: 6112103 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No/ r///Pumping information was provided by the owner,occupant,or Board of Health t/ Were any of the system components pumped out in the previous two weeks !/ Has the system received normal flows in the previous two week period? ZHave large volumes of water been introduced to the system recently or as part of this inspection ? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? AV J _ Were all system components, luding the SAS, located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of th baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum? Was the facilityowner(and occupants nts if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no �_ Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1549 Route 6A ez a2n-6 a e, Na.ez. Owner: Estate 0� John / .cc a2 zon Date of Inspection: 6/1210 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms): `��AO= Number of current residents: O Does residence have a garbage grinder(yes or no): 4b Is laundry on a separate sewage system (ye}or no):.GO [if yes separate inspection required] Laundry system inspected(yes or no):y? Seasonal use: (yes or no): 4)0 I/ the we-UP h a z n o t Water meter readings, if available(last 2 years usage(gpd)):Zia Been t ez t ed in t h e Sump pump(yes or no): 0 /2a,3t 12—month6. It .6houid Last date of occupancy:yUA99 C; ge done at thi.3 time. COMMERCIAL/INDUSTRIAL See Ra ye,3 6A 9 613 Type of establishment: JU Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): All Grease trap present(yes or no):d& Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):/1, Water meter readings, if available: Last date of occupancy/use: OTHER(describe): .l7i>7 GENERAL INFORMATION Pumping Records Source of information: l4-9>� .//.(�', l.G.r7�' 0�6 Was system pumped as part of the inspection(yes or no):" If yes, volume pumped: O gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system �JQ Single cesspool Overflow cesspool _Privy IShared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 4dTight tank -j�Attach a copy of the DEP approval 10- Other(describe):_ Am Ap roxi ate age of all c mponents,date inst led(if known)andsource of information: ` ��- - � �r I Were sewage odors detected when arriving at the site(yes or no): 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1549 /Route 6A Uezt Ba2n.3tagie, l7ae�s. Owner: Eztate 0, 1. /2icha zd,3on Date of Inspection: 6112103 BUILDING SEWER(locate on site plan) D Depth below grade: / Materials of construction:_cast iron t�40 PVC4,0 other(explain): V0 Distance from private water supply well or suction line:.0,4'0 Comments(on condition of joints, venting, evidence of leakage, etc.): ?niT}.ti rirn�nonn fighf_ No ouirlonre ae PPnkngo_ 7•ho ,tUAYpm i.b vented thlzough the house vent.e. SEPTIC TANK: Y (locate on site plan) 1"90 0424E Depth below grade: Material of construction: i,-cOncrete4/O meta ly&fiberglassAkSolyethylene /!I�.other(explain) A 7 If tank is metal list age:.&/D Is age confirmed by a Certificate of Compliance(yes or no):'y4(attach a copy of certificate) �� ( Dimensions: _b'! k4� Sludge depth: � Distance from top of sludge to bottom of outlet tee or baffle:� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: -t-U How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): ')um,? .5p.12Lic irzak eve2U 2-3 Uea2,s. lniet 9 outiet tee.6 ate in Reace, The tank i.6 -stauctu2a—.2u .6ound and 6how.6 no evidence o� .Peakage. GREASE TRAP �Y(locate on site plan) Depth below grade: Material of construction,�f�concrete,�/'AmetaMly9fiberglass�l//polyethylene�/14 other (explain): /� Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: .Z0 Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): rnonAo Igo i.t nnf pRo.tonf' _ J r r 7 f Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1549 Route 6R e.s a/m a e, Ma.a.s, OWner:Ehtate 0,P 1. RichaAd.6on Date of Inspection: 6/12103 TIGHT or HOLDING TANK4&,V—(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:dld concrete d/0 metaIA& fiberglass 40—yolyethylene4/44 other(explain): Dimensions: AA Capacity: allons Design Flow: A14 gallons/day Alarm present(yes or no): Alarm level: M Alarm in working order(yes or no):W.4_ Date of last pumping:_JA Comments(condition of alarm and float switches, etc.): 71ght o2 ho—Rding tank,3 ate no -/2/ie.6ent. DISTRIBUTION BOX.: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids oarryover, any evidence of leakage into or out of box,etc.): �11;AL7.iP�, _on gox hays two .Pateaa.Pz, No evidence o,� •soP cl� ca22y ove2 No evidence O ea aye <nzo vac out, v� the ,avA., PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no): 4.49 Alarms in working order{yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump eham9e2 i,3 not R2e.6ent 8 I 1 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:1 549 Route 64 Vezt 13azn.6tagte, Nazz. Owner: u'atate . / is h a- aon Date of Inspection: 6/1210 3 SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) 2- 1000 4a-Pion R2eeaa1- 2each.ing p.ita. If SAS not located explain why: r o c a t e d • Sag Q Q 9 A I n Type ✓ leaching pits,number: leaching chambers,number: 440 leaching galleries, number: Q ,40 leaching trenches,number, length: 6 leaching fields,number,dimensions: 6 overflow cesspool,number: Q innovative/alternative system Type/name of technology:) Ale)e) [2, m Coments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,conditio5ovegetation, etc.): Loam t/ aand to ciau mixed aand to ,P-ine nand No a.igna o,,,,' hyd2au.P.ic Za-i.2u2 o/z /2ondiny So-i—Ra a/ze d2c/, Vege.tat ion .ia no2maP. Both o� .the /?.ita ate /z2eaent.2y d2y. CESSPOOLStk/e, (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): CeaaRooi.6 ate not n2eaent. PRIVYA&G (locate on site plan) Materials of constructi n' Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 1 ni»y ;A nnf o1,,v,son1 9 Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; 1549 Route 6A ez t 13 aan.6 a e, Nd.6,s. Owoer4-3tat,e . cc a2 zo2 , Date of Inspection; /03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where publie.�water supply enters the building. 1549 CA 1 :A/ _ p t 10 Page 11 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1549 /2ou.t e 6A iV ens t 13 a/t n Tt a e, Na-3.a. Owner: a. /2ec 72 Y.6on Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 0 feet Please indicate(check)all methods used to determine the high ground water elevation: NgL_Obtained from system design plans on record-If checked,date of design plan reviewed: NA qLS_Observed site(abutting properry/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: NA q S Checked with local excavators, installers-(attach documentation) if Accessed USGS database-explaiM.t t A- /t mmn P n an 6 f r,.Qe. ma, u.6. You must describe how you established the high ground water elevation: Used: Gahaetu 9 Mi.e.Pea Node.P. 12116194 Gawind wri}on o0ouni and r:Bc)¢ Aea Rove.2. Deed: 1ZSgS: ZgP4 bb6684 4P, 99PA :Q 9c1 Q00 Ppr1i; Annijnf RnngoZ aA panuar/ mri e2 e2euat�or 1rr /irinri 1992 n Leaching i! Pit Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bonom of the leaching pit and the adjusted groundwater table is feet. 11 1 r y.,•rrnr+,-nrr+•-.-+-r' rnrmr•nsrnar�nnxsnrs*arrtse++�rrt�ro*e.nm ervrnZ T+�rtert.�s �,r�...-. r...F 1 TOWN OF BOARD OF HEALTH l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION T •.•rrz ter•..-::,--air.-.--nwr.n•rt.•nn rw�+ss'rrn-nn-r•t+�mn�.aenn-�'�+n+�sr swan ..-,I_rr•r•�. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 1549 Route 6A Ve.3t Bannetagie, Pia.6.,. ASSESSORS MAP, BLOCK AND PARCEL # 197-007 OWNER' s NAME Cztate 0/ Rtchaadzon PART D - CERTIFICATION I NAME OF INSPECTOR aozeph P. Macomgea ;a. COMPANY NAME Z_,_P. Macomge2 & Son Inc COMPANY ADDRESS Box 66 Centeay.t2.2e, Na,s.a. 02632 Stre9t Town or City Stat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 _ 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage diaposa7 system at ®rtecommendat' ions his address and that the information reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . n i III;{ I, Chec one: System PASSED The inspection ;4hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con trc,ted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date ✓r ne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or"operator shall upgrade system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3,10 CMR 16 . 305 . partd .doc New England ChromaChem 6 Nichols Street Salem,MA 01970 978-744-6600 Massachusetts DEP Lab.M-MA072 Sample Information EPA Method 624.2 Rev 4.1 Volatile Organic Compounds in Water Lab ID: 606161 Client: Envirotech Laboratory,Inc. Client 1D: DW-161758 State: Liquid Date Sampled: 06/13/16 Date Received: 06/15/16 Date Analyzed: 06/15/16 cL Regulated VOC's Results(ug/L) (ug/L) Unregulated VOC's Results ug/L Benzene NO 5 Acetone NO Carbon Tetrachloride NO 5 Bromobenzene NO 11-Dichioroethene NO 7 Bromochtoromethane NO 1.2-Dichloroethane NO 5 Bromodichloromethane NO 12-Dichiorobenzene NO 600 Bromoform NO 14-Dichiorobenzene NO 5 Bromomethane NO Trichloroethene NO 5 2-Butanone NO 1,1,1-Tdchloroethane NO 200 N-Butylbenzene NO Vinyl Chloride NO 2 Sec-Butvlbenzene NO Chlorobenzene NO 100 Ted-Butylbenzene NO cis-1,2-dichloroethene NO 70 Chloroethane NO trans-1,2-dichloroethene NO 100 Chioroform NO 1,2-Dichioro ro ane NO 5 Chloromethane NO ° Ethylbenzene NO 700 2-Chlorotoluene NO Styrene NO 100 4-Chlorotoluene NO Tetrachloroethene NO 5 Dibromochloromethane NO Toluene NO 1000 1 2-Dibromo-3-Chloro ro ane NO X enes Total NO 10000 1 2-Dibromoethane NO Methylene Chloride NO 5 Dibromomethane NO 1,2 4-Tdchlorobenzene NO 70 1 3-Dichlorobenzene ND 112-Trichioroethane NO 5 Dichlorodifluoromethane NO 1,1-Dichloroethane NO 1 3-Dichloro ro ane NO 2 2-Dichloro ro ane NO 1,1-Dichloro ro ene NO Hexachlorobutadiene NO Iso ro benzene NO P-Isopropyltoluene NO Methyl-tert-butyl ether NO Naphthalene NO N-Propylbenzene NO 1.1,1,2-Tetrachloroethane NO 1,1 2 2-Tetrachloroethane NO 12,3-Trichlorobenzene NO Trichlorofluoromethane NO 1,2,3-Trichlora ro ane NO 1,2,4-Trimeth benzene IND 1 3,5-Trimeth (benzene ND Method Detection Limit 0.5 uIL Recoveries of Internal Standards Benzene-d6 99 4-Bromofluorobenzene 91 MCL TTHM's=80 ug/L 1,2-Dichlorobenzene-d4 1105 Method Detection Limit=0.5 ug/L _ Analysis performed per 310CMR42 Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 6/16/2016 f i � 7 L . TOWN OF BARNSTABLE SEWAGE # 23- 17-3 VILLAGE G,/ t3g,n.r✓c�d le- ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO.E�,/�.�J�;�y�,��,�- L.PTIC TANK CAPACITY r `_BEACHING FACILITY:(type) J�T (size) j NO. OF BEDROOMS ,3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ( �evr�J 'li DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ti/ I I�\ ��/` ' i � � a, � � ® 0 __ �i � � 9z� ��-' /Uf�� 1 fir- 9 � . No....Y.�1—.1. � /11F ..... ....3�J.00 THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOAR® OF HEALTH Barnstable Conservatlot: j, 3'' r cnt R 11 G TOWN OF BARNSTABLE Signed APPHAMon for Diripoiul Works Tonoarnr#"ton rantit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: 1549 Route--O_ 6A tiie.s:t_Barns table .....--••--•-"""............................................•.......-•-------.--------•---_...-• ------•-•-----•--.....__.....-------•---•-•-•------...---••------•------•--•------.....---........ Richardson Location-Address or Lot No. Owner Address W J.P.Macomber Jr/ Installer Address d Type of Buil ing Size Lot............................Sq. feet Dwelling—No. of Bedrooms.---.---..-3...............---------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -----------------_----.---- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow.........................................,..gallons. WSeptic Tank—Liquid capacity........---gallons Length................ Width-.---------.---. Diameter....------------ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------.-_-------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..........................------........ ,.� Test Pit No. 1----------------minutes per inch Depth of Test Pit....--.............. Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.....----........... Depth to ground water.--..................... a ...................................•----.............................................--•----•--•----......................................................... o D S etcq]g°n&f G v W --------- -----------------------------------------------------------------------------------••------------• ---- x 1-IO�J aZ1"ori Teac�i"iris ply: U N t e, f,Re at s or Alterations—Anse er he a li able............._-..-------.:..__..---.-----.---._......._.....--.................................. �c�dtl�io�i �o an existing tan`` �c Pi`t. Agreement-. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�beissued by the bo rd of health. SignedA lr.... ..,............................... � (�93 . 1 ............................... Date Application Approved By ........... ........ .. .. ....-- Application Disapproved for the following reasons: ................................... ...................................................................... ........................ ....... .............. . ...................................... . ....................... ......................... ............................................... . . ------..........Dare Permit No. ........qq.. ....................... L.- �........L.7,� ................. Issued .................................................................... Dare .f T�..-.-..y-.-.»---e-.-..-..-.......-..---•�.....,,_`�,,��.1.-.,-.;rM.-r..�-.-•�-.. ,c:.•.-a-..,.--s•ty-.:��...Y,.J,y,.a.. 7/Finz NO....e.s.....� -��. THE COMMONWEALTH � 3�.�� / OF MASSACHUSETTS f l _ ...................... . BOARD OF HEALTH q -7 TOWN OF BARNSTABLE Appliration for Diripniul Works Tonstrnr#inn rumit Application is hereby made for-a Permit to Construct ( ) or Repair {XT, an Individual Sewage Disposal System at t Location- Address or Lot No. R_.y_Gt� rd s on ------------------ --- ----------------------------------------- -••---------•-------------------------•---•-----................----------•---------••--•-------•- W J.P.Macomber Jr/ O+rncr Address Installer Address UType of Buil i g Size Lot.................... ......Sq. feet t-, Dwellin '—No. of Bedrooms.--_--_--__3__________________--_----__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons--------------............__ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------------------ ------- ----------- ----------------------------•------------------------.- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No.--_---_-_-........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. •z Other Distribution box ( ) Dosing tank ( ) ~t Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................lnmutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------•----...-------••---•--------••------------•---••-------.....---•--..............---......................................................... 0 De ription of .5- il._ at1ua..... W .........-•---------------------------------•----••.........----•--------------------------•..----------•--_- - ~t F r - x T-1J,�J___( alori___leacnin ' .............._. U Nature of Repairs or Alteratipns-Answteran�hen ap_p I? le----------------------------------------------------------------------------------------------- Addition to an existlnf PP ...----..-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed �� ,��r% A�. ----------------------------- /16/93 ........... ...................... Date Alication Approved B �..�.< ,t ------------------------------------ ------------- i{.....-.tea........_?� PP PP Y ........... -. ........ .. ...... - f`Due Application Disapproved for the following reasons: .........._.._....................................................................... ....._.............................--.... ..................................................................................................................... -. .. -. ........ ..- .. .... ........................................ q � Dare PermitNo. r.... ....". -1.7 - Issued ............................................. ............ Dare ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ILlPrtifirate of Taraylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) byJ.P.Macomber Jr. ..... -- .. .. ..... .. ......... ............. ..... ....................... .... at � 4: D :.. �. ::I�I Y` :b' lA .. .. ........... ... .. . ......._... ............... . . ......... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _)..7..3 ....... dated ..........................................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE _...._.. .......5... ...��.'. ----------- ....................... Inspector ............ ..: ....-...................................................... -----------------------------------------------------------------------� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.....q .1 7 FEE.TOWN OF BARNSTABLE .........3p.00 ./...:��.�. .. ..... Disposal Works Tunitr tuan "rrntit J.P.Macomber Jr. Permissionis hereby granted.......... ........................................................ -------------•---•----------------•----•-----------.....----............. to Constr _( r) - rY R r. i� F lean Tlnc i.dii�1,S-raw Age Disposal System at N o. 5 = 49 = t.-�': �if�. l i9�C1 . street y� as shown on the application for Disposal Works Construction Permit _-1Z�_._ Dated........................................... IJ �y Board of Health DATE----....--•------...•.=l•.n_&..... _3........................... 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